Panic Disorder and Migraine: Comorbidity,Mechanisms, and Clinical Implications

A growing body of literature suggests that comorbid anxiety disorders are more common and more prognostically relevant among migraine sufferers than comorbid depression. Panic disorder (PD) appears to be more strongly associated with migraine than most other anxiety disorders. PD and migraine are both chronic diseases with episodic manifestations, involving significant functional impairment and shared symptoms during attacks, interictal anxiety concerning future attacks, and an absence of identifiable secondary pathology. A meta‐analysis of high‐quality epidemiologic study data from 1990 to 2012 indicates that the odds of PD are 3.76 times greater among individuals with migraine than those without. This association remains significant even after controlling for demographic variables and comorbid depression. Other less‐rigorous community and clinical studies confirm these findings. The highest rates of PD are found among migraine with aura patients and those presenting to specialty clinics. Presence of PD is associated with greater negative impact of migraine, including more frequent attacks, increased disability, and risk for chronification and medication overuse. The mechanisms underlying this common comorbidity are poorly understood, but both pathophysiological (eg, serotonergic dysfunction, hormonal influences, dysregulation of the hypothalamic–pituitary–adrenal axis) and psychological (eg, interoceptive conditioning, fear of pain, anxiety sensitivity, avoidance behavior) factors are implicated. Means of assessing comorbid PD among treatment‐seeking migraineurs are reviewed, including verbal screening for core PD symptoms, ruling out medical conditions with panic‐like features, and administering validated self‐report measures. Finally, evidence‐based strategies for both pharmacologic and behavioral management are outlined. The first‐line migraine prophylactics are not indicated for PD, and the selective serotonin re‐uptake inhibitors used to treat PD are not efficacious for migraine; thus, separate agents are often required to address each condition. Core components of behavioral treatments for PD are reviewed, and their integration into clinical headache practice is discussed.     

Nonmotor complications of Parkinson disease

Nonmotor manifestations are integral components of Parkinson disease (PD), and they often have a greater impact on disability and quality of life than the motor features that currently define the illness. Nonmotor features of PD, such as dementia, may be an intrinsic feature of the disorder and persist regardless of the medication state (ie, they continue to manifest in the "on" or "off" state); some nonmotor features, such as psychotic symptoms, may be iatrogenic complications of pharmacologic intervention for the treatment of the motor manifestations of PD. Iatrogenic complications, such as psychosis and impulse control disorders, may respond to modification of the PD treatment regimen at the risk of worsening motor symptoms. Thus, a balance must be struck between controlling nonmotor manifestations and motor features of the disease.     

The Broad Clinical Spectrum of Neuroblastoma

The wide range of clinical manifestations of neuroblastoma forces clinicians to keep this tumor in mind at all times. Initial symptoms may arise from the primary lesion or from metastases. Diagnosis may be obvious or obscure. This discussion details the symptoms and physical and x-ray findings of neuroblastomas originating in the head, neck, chest, abdomen, pelvis and spine.     

Managing the patient with newly diagnosed Parkinson disease

The treatment of early Parkinson disease (PD) is generally symptomatic, although therapy that also offers neuroprotection in early-stage PD would be welcomed. Levodopa remains the most effective agent for relief of PD symptoms, but chronic levodopa therapy is associated with motor fluctuations and dyskinesias, and clinicians may therefore opt to postpone its use. Alternatives to levodopa in early PD include monoamine oxidase (MAO)-B inhibitors, amantadine, and dopamine agonists. MAO-B inhibitors have only mild symptomatic effects. Amantadine is associated with improvement in functional disability and, in a subset of PD patients, a robust symptomatic improvement. Dopamine agonists improve symptoms and may have a neuroprotective effect. Partial dopamine agonists, adenosine A(2A)-receptor antagonists, and safinamide are symptomatic therapies that are under investigation. Neuro protective strategies under study include enhancement of mitochondrial function, antiinflammatory mechanisms, calcium channel blockade, and uric acid elevation. Deep brain stimulation may slow cognitive and motor decline when used in early PD. Stem cell therapy and gene therapy are still under investigation.     

改善循环治疗加重帕金森病患者体位性低血压1例

目的 提醒临床医生加强对于帕金森病(Parkinson’s disease, PD)患者非运动症状的关注。方法 追踪报道1例帕金森病合并高血压患者,接受调整抗PD药物、降压及改善循环治疗的效果。结果 该患者治疗过程中出现了严重的体位性低血压、晕厥。结论 临床医生应重视PD患者的体位性低血压等非运动症状。     

Dermatologic manifestations and complications of COVID-19

The novel coronavirus disease of 2019 (COVID-19) is associated with significant morbidity and mortality. While much of the focus has been on the cardiac and pulmonary complications, there are several important dermatologic components that clinicians must be aware of.ObjectiveThis brief report summarizes the dermatologic manifestations and complications associated with COVID-19 with an emphasis on Emergency Medicine clinicians.DiscussionDermatologic manifestations of COVID-19 are increasingly recognized within the literature. The primary etiologies include vasculitis versus direct viral involvement. There are several types of skin findings described in association with COVID-19. These include maculopapular rashes, urticaria, vesicles, petechiae, purpura, chilblains, livedo racemosa, and distal limb ischemia. While most of these dermatologic findings are self-resolving, they can help increase one's suspicion for COVID-19.ConclusionIt is important to be aware of the dermatologic manifestations and complications of COVID-19. Knowledge of the components is important to help identify potential COVID-19 patients and properly treat complications.     

Clinical review of treatment options for select nonmotor symptoms of Parkinson's disease

Background: Parkinson's disease (PD) is associated with a host of nonmotor symptoms, including psychosis, cognitive impairment, depression, sleep disturbance, swallowing disorders, gastrointestinal symptoms, and autonomic dysfunction. The nonmotor symptoms of PD have the potential to be more debilitating than the motor features of the disorder.Objective: The aim of this article was to review treatment options for the nonmotor manifestations of PD, including pharmacologic and nonpharmacologic interventions.Methods: The PubMed and MEDLINE databases were searched for articles published in English between January 1966 and April 2010, using the terms Parkinson's disease, nonmotor, psychosis, hallucination, antipsychotic, cognitive impairment, dementia, depression, sleep disturbance, sleepiness, REM (rapid eye movement) sleep behavior disorder, dysphagia, swallowing disorder, sialorrhea, gastrointestinal, constipation, autonomic dysfunction, orthostatic hypotension, gastroparesis, erectile dysfunction, sexual dysfunction, and urinary dysfunction. Articles were selected for review if they were randomized controlled trials (RCTs), meta-analyses, or evidence-based reviews of treatment of patients with PD, and/or expert opinion regarding the treatment of nonmotor symptoms of PD.Results: A total of 148 articles, including RCTs, meta-analyses, and evidence-based reviews, were included in this review. The treatment of hallucinations or psychosis in PD should include a stepwise reduction in medications for motor symptoms, followed by the use of quetiapine or clozapine. Dementia may be treated with acetylcholinesterase inhibitors. Evidence is lacking concerning the optimal pharmacologic treatment for depression in PD, with expert opinions indicating selective serotonin reuptake inhibitors as the antidepressants of choice. However, the largest study to date found nortriptyline therapy to be efficacious compared with placebo, whereas paroxetine controlled release was not. A variety of sleep disturbances may plague a person with PD, and treatment must be individualized to the patient's specific sleep disturbance pattern and contributing factors. Swallowing disorders may lead to aspiration and pneumonia, and patients with dysphagia should be referred to a speech therapist for further evaluation and treatment. Orthostasis may be treated with nonpharmacologic interventions as well as pharmacologic treatments (eg, fludrocortisone, midodrine, indomethacin). Other autonomic symptoms are managed in a manner similar to that in patients without PD, although careful attention must be aimed at avoiding dopamine-blocking therapies in the treatment of gastrointestinal dysfunction and gastroparesis.Conclusions: Various pharmacologic and nonpharmacologic strategies are available for the management of the nonmotor symptoms of PD. The challenges associated with nonmotor symptoms must not be forgotten in light of the motor symptoms of PD, and treatment of nonmotor symptoms should be encouraged.     

Dual threat of comorbidity of celiac disease and systemic lupus erythematosus

Celiac disease (CD) is a chronic immune-mediated intestinal disease that is characterized by production of autoantibodies directed against the small intestine. The main clinical manifestations of CD are typically defined as those related to indigestion and malabsorption. These manifestations include unexplained diarrhea or constipation, abdominal pain, bloating, weight loss, anemia, failure-to-thrive in children, and decreased bone density. Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by heterogeneous clinical manifestations, which may also involve the gastrointestinal tract. Comorbidity of CD and SLE is rare, and the overlapping symptoms and nonspecific clinical presentation may pose a diagnostic challenge to clinicians. We report here a case of SLE with CD, which mainly manifested as recurrent diarrhea, uncorrectable electrolyte disorders, and severe malnutrition. Through review, we hope to further improve our understanding and diagnostic level of this combination of diseases.     

Hepatitis A and HIV: a clinical review of disease and strategies for prevention.

Hepatitis A, also known as infectious hepatitis, remains one of the more commonly transmitted types of viral hepatitis in the United States. Given the high prevalence of this illness, clinicians need to be aware not only about the clinical manifestations of this disease, but also about the special considerations that must be taken into account for persons coinfected with HIV. Antiretroviral management during acute hepatitis infection may be complicated by elevations of serum liver enzyme tests as well as by severe manifestations of associated symptoms such as nausea and vomiting. This article provides a brief overview of the clinical course of HIV infection and includes recommendations for antiretroviral medication management during acute illness. Additionally, strategies for prevention of disease are presented, with a focus on the efficacy and use of hepatitis A vaccines in persons with HIV.     

A focal infiltration in the upper lobe of the right lung as a manifestation of the initial stage of secondary syphilis

Among sexually transmitted diseases, the incidence of primary and secondary syphilis has substantially increased in Russian Federation within the recent years. Modern clinicians, acquainted only with conventional dermatovenerologic symptoms of the disease, are less aware of rare manifestations of syphilis as a generalized infection. A rare case of syphilis with infiltrative pulmonary lesion is discussed in the article; the attention of practitioners is drawn to "unusual" manifestations of syphilis.     

Medication Adherence and HIV Symptom Distress in Relation to Panic Disorder Among HIV-Positive Adults Managing Opioid Dependence

Panic disorder (PD) occurs at greater rates among those with HIV compared to those without HIV. Rates of PD may be elevated among those with opioid dependence (persons who inject drugs, PWID). Persons with HIV experience common bodily symptoms as a result of the disease and these symptoms overlap with those of PD which may contribute to a “fear of fear” cycle present in PD. HIV-positive, PWID represent an at-risk population in terms of poor medication adherence. HIV symptoms and HIV medication side-effects commonly overlap with panic symptoms and may affect HIV medication adherence. The aim of this investigation was to examine the impact of PD on HIV-related symptom distress and HIV medication adherence in HIV-positive adults (N = 131) in treatment for opioid use. Those with a diagnosis of PD evidenced greater levels of HIV symptom distress and lower levels of medication adherence than those without current PD. Results highlight the clinical importance of assessing for and treating PD among individuals with HIV that are prescribed antiretroviral therapy. Future work would benefit from examining observed associations longitudinally and identifying potential mechanisms involved.     

Fall risk factors in Parkinson's disease.

Parkinson's disease (PD) is a neurodegenerative disorder characterized by tremor, rigidity, bradykinesia, gait disturbance, and postural instability. Patients with PD suffer frequent falls, yet little research has been done to identify risks specific to PD patients. The objective of this study was to identify the risk factors associated with falls for PD patients through the collection of demographic, environmental, and medical information as well as fall diaries completed during a 3-month period. Patients with a diagnosis of idiopathic PD, with and without falls, were included in the study provided they could stand and walk and had no other condition that could predispose them to falls. Of the 118 participants, 59% reported one or more falls. A total of 237 falls were reported. Duration and severity of PD symptoms, particularly freezing, involuntary movements, and walking and postural difficulties, were significantly associated with an increased risk of falls. Other factors associated with falls were postural hypotension and daily intake of alcohol. Forty percent of falls resulted in injury, but serious injury was rare. The findings have implications for reducing the risk of falls through patient education.     

The many 'faces' of Graves' disease. Part 1. Eyes, pulse, skin, and neck provide important clues to diagnosis.

The variety in clinical appearance of patients with Graves' disease suggests that predominant symptoms affecting one body system may be either compelling or misleading to clinicians during the initial assessment. However, each patient in these case presentations had additional bedside evidence of many of the recognized multisystem manifestations of hyperthyroidism, as detected on more extensive evaluation. Laboratory tests confirmed the diagnosis in each instance. While these cases are not meant to represent all reported manifestations of Graves' disease, grouping of symptoms into memorable "faces" is helpful for definitive clinical recognition and precise diagnosis of this complex and challenging syndrome.     

Functional brain networks and abnormal connectivity in the movement disorders

Clinical manifestations of movement disorders, such as Parkinson's disease (PD) and dystonia, arise from neurophysiological changes within the cortico-striato-pallidothalamocortical (CSPTC) and cerebello-thalamo-cortical (CbTC) circuits. Neuroimaging techniques that probe connectivity within these circuits can be used to understand how these disorders develop as well as identify potential targets for medical and surgical therapies. Indeed, network analysis of (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) has identified abnormal metabolic networks associated with the cardinal motor symptoms of PD, such as akinesia and tremor, as well as PD-related cognitive dysfunction. More recent task-based and resting state functional magnetic resonance imaging studies have reproduced several of the altered connectivity patterns identified in these abnormal PD-related networks. A similar network analysis approach in dystonia revealed abnormal disease related metabolic patterns in both manifesting and non-manifesting carriers of dystonia mutations. Other multimodal imaging approaches using magnetic resonance diffusion tensor imaging in patients with primary genetic dystonia suggest abnormal connectivity within the CbTC circuits mediate the clinical manifestations of this inherited neurodevelopmental disorder. Ongoing developments in functional imaging and future studies in early patients are likely to enhance our understanding of these movement disorders and guide novel targets for future therapies.     

Clinical manifestation of pulmonary embolism.

Results of prospective studies have shown that physicians' estimate of clinical likelihoods of PE have predictive value. The ability of clinicians to assess the factors that determine the probability of disease based on clinical manifestations such as history and signs and symptoms at presentation, and to make bedside estimates of that probability, has not been systematically studied. Data suggest that that this would be a fruitful area of future investigation. Susec et al noted that there has been a total of three studies (including their own) which have examined the clinical features such as risk factors, signs, and symptoms associated with PE in ambulatory outpatients. Hence, the data collected thus far might not be generalizable to the ED patient population. As with other illnesses, the ED patients usually present later and more atypically. The prevalence of PE could be lower among this population compared with hospitalized patients, causing a lower positive predictive value, derivable from the clinical features and risk factors at presentation. Finally, the ED patient population is usually healthier and younger than the hospitalized patients, and it is well recognized that PE can be clinically silent in young patients and that 28% have no associated risk factors. Based on their finding, the authors argue that clinical pathways to risk stratify patients in an ambulatory setting could be less useful than anticipated. The validity of these findings needs further investigation, however.     

Menopause-associated metabolic manifestations and symptomatology in HIV infection: a brief review with research implications

Many women living with HIV in the United States have entered or will soon enter menopause. Clinical changes including increased visceral fat, reduced muscle mass, and changes in lipids and bone density are seen across the menopause transition among non-infected women. HIV and antiretroviral therapy use have been associated with similar manifestations, including reduced bone density, and changes in lipid metabolism and body composition. Menopause is also associated with changes in mood, quality of life, and vasomotor symptoms. Similar psychological indices are common among women with HIV, and may worsen during menopause transition. Research investigating the presence and acuity of metabolic, psychological, and vasomotor symptoms among perimenopausal women with HIV is limited. An important, yet unknown consideration for researchers and clinicians is how metabolic and psychological co-morbidities associated with HIV will influence changes associated with menopause in this population. Further research is needed to provide answers to these important questions.     

Henna (Lawsonia inermis Linn.) induced haemolytic anaemia in siblings

Henna is a traditional cosmetic agent and is used worldwide. It is used worldwide not only as a cosmetic agent to stain the hair, skin and nails but also is applied to the body on lesions in the treatment of seborrheic dermatitis or fungal infections. Different pathologies have been described as caused by henna. The aim of this study is to draw attention to the adverse effects of henna, applied over the whole body, observed in glucose-6-phosphate dehydrogenase (G6PD) enzyme deficient siblings. In the present paper, we report on two siblings with G6PD deficiency who developed haemolytic anaemia following topical application of henna to their whole body to treat skin lesions. Their parents were also found to be G6PD deficient. Even though anti-inflammatory, analgesic and antipyretic effects of henna have been shown, it may cause severe side-effects in some cases. For this reason, especially, in the regions where G6PD enzyme deficiency is common, people should be informed about the side-effects of topical henna application and clinicians should be aware of these manifestations.     

帕金森病相关性肠梗阻的临床研究

目的 研究帕金森病(PD)相关性肠梗阻的临床特点,探讨其发生的原因,总结诊治经验.方法 选取既往被明确诊断为PD的急性肠梗阻患者5例为研究对象,对其临床及影像学表现、从诊断PD到发生肠梗阻的经过时间、合并肠梗阻时的PD用药以及合并肠梗阻时患者的PD严重程度分级等进行调查研究.结果 合并肠梗阻的5例病例的PD发病年龄平均为62.4岁.从诊断PD到发生肠梗阻的经过时间平均7.8年.4例因病情较重实行了开腹手术.结论 PD重症度与并发肠梗阻之间并无一定的关系.因有发生绞窄性肠梗阻的可能,外科医生在临床中应充分认识PD相关性肠梗阻的特点.     

ECG manifestations: noncoronary heart disease

The electrocardiogram reflects changes to the heart beyond those seen in acute myocardial infarction and acute coronary syndromes.Diseases of the pericardium and heart muscle such as pericarditis,myocarditis, and pericardial effusion have characteristic manifestations. Hypertensive heart disease is associated with a variety of changes on the electrocardiogram, as is valvular heart disease. Cardiac rhythm disturbances have been associated with the Brugada syndrome and the long QT syndrome, both of which have telltale findings on the electrocardiogram. The manifestations of dextrocardia, although rare, should be familiar to those who interpret electro-cardiograms. Transplanted hearts also feature classic changes, both in health and in stages of rejection. The various electrocardiographic manifestations of these noncoronary heart diseases are reviewed here.     

Electrocardiographic manifestations of COVID-19

IntroductionCoronavirus disease of 2019 (COVID-19) is a lower respiratory tract infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This disease can impact the cardiovascular system and lead to abnormal electrocardiographic (ECG) findings. Emergency clinicians must be aware of the ECG manifestations of COVID-19.ObjectiveThis narrative review outlines the pathophysiology and electrocardiographic findings associated with COVID-19.DiscussionCOVID-19 is a potentially critical illness associated with a variety of ECG abnormalities, with up to 90% of critically ill patients demonstrating at least one abnormality. The ECG abnormalities in COVID-19 may be due to cytokine storm, hypoxic injury, electrolyte abnormalities, plaque rupture, coronary spasm, microthrombi, or direct endothelial or myocardial injury. While sinus tachycardia is the most common abnormality, others include supraventricular tachycardias such as atrial fibrillation or flutter, ventricular arrhythmias such as ventricular tachycardia or fibrillation, various bradycardias, interval and axis changes, and ST segment and T wave changes. Several ECG presentations are associated with poor outcome, including atrial fibrillation, QT interval prolongation, ST segment and T wave changes, and ventricular tachycardia/fibrillation.ConclusionsThis review summarizes the relevant ECG findings associated with COVID-19. Knowledge of these findings in COVID-19-related electrocardiographic presentations may assist emergency clinicians in the evaluation and management of potentially infected and infected patients.